1. Name of insurance
company

2. Is the company licensed in your state?

3. Name
of insurance agent

4. Is the agent properly licensed?

5.
Insurance company financial ratings

(such as: A.M. Best; Moody’s;

Standard $ Poor’s; Weiss)

Levels of care covered by the policy

6. Does the policy provide benefits for these levels of care? a.
Skilled nursing care? ___________ ___________

b. Personal/Custodial care?
___________ ___________

(In many states, both level of care are required.)

7. Does the policy pay for any nursing home stay, no matter what level of care
you receive?

8. If not, what levels are not covered?

align="left">Where can you receive covered care?

9. Does the
policy pay for care in any licensed facility?

10. If not, what does it not pay
for?

11. Does the policy provide home care benefits for:

align="left"> a. Skilled nursing care?

b. Personal care given by home health
aides?

c. Homemaker services?

d.
Other__________________ ?

12. Does the policy pay for care
received in:

a. Adult day care centers?

b.
Assisted living facilities?

c. Other settings: _________________

align="left">_________________

_________________